Thomas, Alice 1,r m TS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTMICOF
DEATH, LEGIBLY WRITTEN IN DU BLE BLACK INK. gist ed No. °F.%
Dist. No Spa( County... 7-6 4)
' ' yA. � or City (If city,give street address)
Name of deceased f
0 Single, married, w.idewld,
�� t`/�
Se Color or dre�eed (write the word). . Date ofjir .... 19.7 1.
Age Q Years onths.. y/ ..Days Birt plac .!N ' /A` `V,
Cause of Death - O N
Certificate was signe b- te. M.D.
Address .... ....... '--Z► ,Ae-r•
Place of Burial . Removal) '7.0'Wk
(If body is to be te./ :rily held later)
Cemetery.... . Date of Burial 19��/.
(If body is to be temporarily held, fl n space later)
The Certificate of Death containing the above stated particulars, having been present:Ito me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ed the for registration, have recorded it in my L ord with the a ve stated Registered
Numb on• a they EREBY GRANT A PERMIT ,7,g
to /_
(A s)
the ... to hold temporarily/aan//dy��� the body.
(Und ker o persoav charge��o,tt corpse) �r "' to rot se e [ wl)
Dated %' , 19...Y/. (Signed)
Local Registrar
This Permit sufficient for the Removal.(and Interment or Cremation) of a body to any part of the State (subject to local /
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